Coronary Heart Disease
Illness Experience and Health Care
’The heart has reasons that reason cannot know. … We know the truth not only by the reason, but by the heart.’
In this chapter, we consider one of the major diseases of the cardiovascular system, coronary heart disease (CHD). We describe the nature and causes of the illness and its major risk factors. Then we discuss the psychosocial issues of living with CHD, caring for someone with CHD, and the design and testing of interventions. We describe research on cardiac rehabilitation for myocardial infarction and angina patients and the results of recent meta-analyses. The ability to offer interventions that are effective and cost-efficient is a challenge that potentially can be solved using a combination of professional, lay and web-based provision.
What is Coronary Heart Disease?1
1. Figure 22.1 and descriptive material on CHD are courtesy of the National Heart, Blood and Lung Institute: www.nhlbi.nih.gov/health/health-topics/topics/cad [Public domain].
Cardiovascular diseases is a broad category that involves diseases affecting the heart or blood vessels. CHD, also known as ’coronary artery disease’, includes angina and myocardial infarction (heart attack). Other major cardiovascular diseases are stroke, heart failure, hypertension, rheumatic heart disease, cardiomyopathy, heart arrhythmia, congenital heart disease, valvular heart disease, caritis, aortic aneurisms, peripheral artery disease and venous thrombosis.
CHD occurs when the walls of the coronary arteries become narrowed by a gradual build-up of fatty material called atheroma. Myocardial infarction (MI) occurs when one of the coronary arteries becomes blocked by a blood clot and part of the heart is starved of oxygen. It usually causes severe chest pain. A person having a heart attack may also experience sweating, light-headedness, nausea or shortness of breath. A heart attack may be the first sign of CHD in many people. Over time, CHD can weaken the heart muscle and cause heart failure and arrhythmias.
When plaque builds up in the arteries, the condition is called atherosclerosis. The build-up of plaque occurs over many years. Over time, plaque can harden or rupture. Hardened plaque narrows the coronary arteries and reduces the flow of oxygen-rich blood to the heart. If the plaque ruptures, a blood clot can form on its surface. A large blood clot can mostly or completely block blood flow through a coronary artery. Over time, ruptured plaque also hardens and narrows the coronary arteries.
Figure 22.1 Coronary heart disease
(A) shows the location of the heart in the body. (B) shows a normal coronary artery with normal blood flow. The inset image shows a cross-section of a normal coronary artery. (C) shows a coronary artery narrowed by plaque. The build-up of plaque limits the flow of oxygen-rich blood through the artery. The inset image shows a cross-section of the plaque-narrowed artery
Source: National Heart, Blood and Lung Institute (2017). Public domain
If the flow of oxygen-rich blood to your heart muscle is reduced or blocked, angina pectoris or a heart attack can occur.
A heart attack occurs if the flow of oxygen-rich blood to a section of heart muscle is cut off. If blood flow is not restored quickly, the section of heart muscle begins to die. Without quick treatment, a heart attack can lead to serious health problems or death. Over time, CHD can weaken the heart muscle and lead to heart failure and arrhythmias. Heart failure is a condition in which the heart cannot pump enough blood to meet the body’s needs. Arrhythmias are problems with the rate or rhythm of the heartbeat.
Angina pectoris is characterized by a heavy or tight pain in the centre of the chest that may spread to the arms, necks, jaw, face, back or stomach. Angina symptoms occur when the arteries become so narrow from the atheroma that insufficient oxygen-containing blood can be supplied to the heart muscle when its demands are high, such as during exercise. There are two categories of angina: stable or unstable angina. Stable angina is characterized by chest pain relieved by rest, resulting from the partial obstruction of a coronary artery by atheroma. Unstable angina occurs with lesser degrees of exertion or while at rest. This type increases in frequency and duration and worsens in severity. Unstable angina is an acute coronary syndrome requiring immediate medical attention. This is usually caused by the formation of a blood clot at the site of a ruptured plaque in a coronary artery. If left untreated, it can result in heart attack and irreversible damage to the heart.
Treatments for CHD include lowering blood pressure, preventing blood clots, which can lead to heart attack or stroke, preventing or delaying the need for a stent or percutaneous coronary intervention (PCI), or surgery, such as coronary artery bypass grafting (CABG). Invasive treatment may be necessary when medication alone does not relieve angina. Referral to a cardiologist or a heart surgeon may be required for further treatment to gain effective control of angina symptoms and for some people to prolong life. Invasive revascularization treatment may include either a PCI or CABG surgery.
Globally, CHD is recognized as the leading cause of death and is predicted to remain so for the next ten years Each year, approximately 3.8 million men and 3.4 million women die from CHD. In 2020, it is estimated that CHD will be responsible for a total of 11.1 million deaths globally. Someone suffers a coronary event every 26 seconds, and someone dies from one every minute in the USA. In Europe, between one in five and one in seven European women die from CHD, and the disease accounts for between 16% and 25% of all deaths in European men (Mathers and Loncar, 2006). Angina is the most common form of CHD with 10 million people in the USA and 2 million in the UK suffering from it. Angina is common among older adults. In England, one in every 12 men and one in every 30 women between 55 and 64 years of age have angina. This figure rises to one in every seven men and one in every 12 women who are over 65 years of age. Angina is more common in men than women. Figure 22.2 shows observed age-adjusted death rates for cancer and heart disease since 1969 and projected to 2020.
The ’bad news’ in Figure 22.2 is the increasing deaths from cancer (see Chapter 21). The ’good news’ is that the incidence of heart disease, including CHD, is declining. Another piece of good news is that CHD, along with most cardiovascular diseases, can be prevented by addressing behavioural risk factors such as tobacco use, unhealthy diet, obesity, inactivity and abuse of alcohol. There is a major role for health psychology in the design and dissemination of high-quality, evidence-based interventions. Another role for health psychology is that people with cardiovascular disease and people at high cardiovascular risk require early detection and management using counselling and medicines.
Figure 22.2 The changing incidence of cancer and heart disease rates in the USA
Source: Weir et al. (2016). Public domain
Risk factors for CHD include:
· increasing age;
· male sex;
· tobacco smoking;
· high blood cholesterol;
· high blood pressure;
· physical inactivity;
· obesity and overweight;
· diabetes mellitus;
· high alcohol consumption;
· sleep disordered breathing;
· low social support/isolation;
· oxidative stress;
· C-reactive protein concentration;
· work stress/burnout/vital exhaustion;
· caregiving for a disabled or ill spouse for more than 9 hours per week;
Many of these risk factors are well established. However, others on the list overlap with each other so are difficult to completely disentangle as independent risk factors. Recent studies have focused on psychosocial and behavioural risk factors. Enter the health psychologist.
Kivimäki and Siegrist (2016) reviewed evidence on work stress as a risk factor for CHD and stroke, with a particular emphasis on ’effort—reward imbalance’ (ERI). Their findings from meta-analyses of cohort studies suggested that individuals with ERI or job insecurity have an increased risk of CHD, while those working long hours appear to be at an increased risk of stroke. They concluded that excess risk associated with ERI was not attributable to other well-established work stressors, such as job strain.
Another alleged risk factor is Type D or ’distressed’ personality (Denollet et al., 1996; see below). The size of the effect of Type D on prognosis appears to have been overestimated and claims have decreased as more studies have been conducted (Grande, 2012).
Similarly, depression has been controversial as a risk factor for CHD. Nicholson et al. (2006) carried out a meta-analysis of depression among 146,538 participants in 54 observational studies of CHD. Results needed to be adjusted for left ventricular function, a risk factor for CHD, but such results were available in only eight studies. It was concluded that depression had yet to be established as an independent risk factor for CHD. However, more recent studies with large samples appear to be more conclusive.
Daskalopoulou et al. (2016) examined the risk of 12 cardiovascular diseases according to depression status, whether historical or new onset. They carried out a cohort study of a large sample of nearly 2 million adult men and women, free from cardiovascular disease at baseline, using linked UK electronic health records between 1997 and 2010. The exposures were new-onset depression based on a new GP diagnosis of depression and/or prescription for antidepressants during a one-year baseline, and history of GP-diagnosed depression before baseline. The primary endpoint was initial presentation of 12 cardiovascular diseases after baseline. Over a median of 6.9 years of follow-up, 18.9% had a history of depression and 94,432 cardiovascular events occurred. After adjustment for cardiovascular risk factors, history of depression was associated with stable angina, unstable angina, myocardial infarction, unheralded coronary death, heart failure, cardiac arrest, transient ischemic attack, ischemic stroke, subarachnoid haemorrhage, intracerebral haemorrhage, peripheral arterial disease, and abdominal aortic aneurysm. New-onset depression developed in 2.9% of people, among whom 63,761 cardiovascular events occurred. New-onset depression was similarly associated with each of the 12 diseases, with no evidence of stronger associations compared to a history of depression. The strength of association between depression and these cardiovascular diseases was not found to differ between women and men. The results of this large, well-controlled study seem fairly conclusive and depression can be accepted as a risk factor for a range of cardiovascular diseases. The precise mechanism remains uncertain.
Living with CHD
The way a person adjusts to CHD is dependent on many different factors, including their personality, support mechanisms, habits and work—life balance. Some research has focused on ’cognitive adaptation’, which can be scored and used as a predictor of psychological adjustment. Helgeson and Fritz (1999) tested whether people with high cognitive adaptation scores would be less vulnerable to a new coronary event due to restenosis within six months of initial PCI. Three components of cognitive adaptation were measured: self-esteem, optimism and control. Patients with a low cognitive adaptation score were more likely to have a new cardiac event even when demographic variables and medical variables thought to predict restenosis were statistically controlled.
Waiting for invasive treatment to improve or prolong life can be very stressful and have deleterious effects on the quality of daily life. The association between CHD and depression has been a major topic for research.
Pre-surgical depression predicts cardiac hospitalization, continued surgical pain, failure to return to previous activity and depression at six months (Burg et al., 2003). Arthur et al. (2000) conducted a trial of a multi-dimensional pre-operative intervention on pre-surgery and post-surgery outcomes in low-risk patients awaiting elective CABG. The intervention consisted of individualized, prescribed exercise training twice per week in a supervised environment, education and reinforcement, and monthly nurse-initiated telephone calls to answer questions and provide reassurance. Patients who received the intervention spent one day less in the hospital and less time in the intensive care unit. Patients in the intervention group reported a better QoL during the waiting period than the control group. The improved QoL continued up to six months after surgery. Using outcome measures such as length of hospital stay as well as QoL measures provides evidence of cost-effectiveness, which is helpful for budget holders wondering whether to invest in such interventions.
Rutledge et al. (2006) carried out a meta-analytic review of prevalence, intervention effects and associations with clinical outcomes of depression in heart failure. Clinically significant depression was present in at least one in five patients with heart failure, but rates can be higher among patients screened with questionnaires. The authors concluded that the relationship between depression and poorer heart failure outcomes is consistent and strong across multiple end points. Unsurprisingly, then, depression is a common response to heart disease.
A special committee of the American Heart Association (AHA) published recommendations for the screening, referral and treatment of depression in heart patients (Lichtman et al., 2008). The committee recommended:
1. Routine screening for depression in patients with CHD in settings, including the hospital, physician’s office, clinic and cardiac rehabilitation centre.
2. Patients with positive screening results should be evaluated by a qualified mental health professional.
3. Patients with cardiac disease who are under treatment for depression should be carefully monitored for adherence to their medical care, drug efficacy and safety with respect to their cardiovascular as well as mental health.
4. Monitoring mental health may include, but is not limited to, the assessment of patients receiving antidepressants for possible worsening of depression or suicidality, especially during initial treatment when doses may be adjusted, changed or discontinued.
5. Coordination of care between health care providers is necessary in patients with combined medical and mental health diagnoses.
In 2013 the National Heart Foundation of Australia proposed similar guidelines to screen CHD patients for depression. It led to more referrals to hospital-based, community and private psychologists.
The AHA recommendations were evaluated using more recent evidence The review of the evidence four years later by Thombs et al. (2013) suggested that the evidence base for this advisory has not, after all, been sufficiently established. Thombs et al. (2013) systematically reviewed evidence on depression screening in CHD by assessing (1) the accuracy of screening tools, (2) the effectiveness of treatment, and (3) the effect of screening on depression outcomes. The authors found few examples of screening tools with good sensitivity and specificity using a priori-defined cut-offs in more than one patient sample. Treatment with antidepressants or psychotherapy generated only modest symptom reductions among post-MI and stable CHD patients, but antidepressants were not reported to improve symptoms more than placebo in two heart failure (HF) trials. Thombs et al. reported that depression treatment did not improve cardiac outcomes. There was evidence that treatment of depression results in modest improvement in depressive symptoms in post-MI and stable CHD patients, although not in HF patients. The authors concluded that ’there is still no evidence that routine screening for depression improves depression or cardiac outcomes. The AHA Science Advisory on depression screening should be revised to reflect this lack of evidence’ (Thombs et al., 2013: 1).
Anger and Hostility
Almost 60 years ago Friedman and Rosenman (1959) showed that patients who exhibited the ’Type A behaviour pattern’ — characterized by competitiveness, excessive drive and an enhanced sense of time urgency — had more risk factors for CHD and were more likely to suffer from major adverse cardiovascular events than patients without the Type A behaviour pattern. Many studies since have found that anger and hostility, as components of the Type A pattern, are associated with the incidence of CHD in both older and younger people.
Kawachi et al. (1996) examined prospectively the relationship of anger to CHD incidence in the Veterans Administration Normative Aging Study with an ongoing cohort of older (mean age, 61 years), community-dwelling men: 1,305 men who were free of diagnosed CHD completed the revised Minnesota Multiphasic Personality Inventory (MMPI-2) in 1986. The participants were categorized according to their responses to the MMPI-2 Anger Content Scale, purporting to measure problems with anger control. During an average of seven years of follow-up, 110 cases of incident CHD occurred, with 30 cases of non-fatal myocardial infarction (MI), 20 cases of fatal CHD, and 60 cases of angina pectoris. Compared with men reporting the lowest levels of anger, the relative risks for men reporting the highest levels of anger were 3.15 for total CHD (non-fatal MI plus fatal CHD) and 2.66 for combined incident coronary events, including angina pectoris. A dose—response relation was found between level of anger and overall CHD risk, suggesting that the higher the level of expressed anger, the higher the risk for CHD among older men.
In another prospective study, Williams et al. (2000) examined the association between anger and the risk of combined CHD (acute myocardial infarction [MI]/fatal CHD, silent MI, or cardiac revascularization procedures) and of ’hard’ events in the form of acute MI/fatal CHD. Participants were 12,986 black and white men and women enrolled in the Atherosclerosis Risk in Communities study. Compared with their low anger counterparts, individuals with high trait anger were at increased risk of CHD in both event categories. On the basis of this study, the evidence suggests that proneness to anger places normotensive middle-aged men and women at higher than average risk for CHD illness and death.
Pollock et al. (2016) used longitudinal measures to examine the prospective influence of anger in young adults. From 1985 to 1986, 768 young adults from the Bogalusa Heart Study completed the State Trait Anger Expression Inventory (STAXI) and were followed for cardiovascular risk factors. The STAXI score is summed from a ten-item test with four response options (1 = ’never angry’; 2=’sometimes angry’; 3 = ’often angry’; 4 = ’almost always angry’). The study population was 63.3% female and 23.2% black. At baseline, age ranged from 17 to 27 years with a mean of 22.7, and the mean STAXI score was 18.6. After a median follow-up of 18 years, anger as a young adult was found to be strongly associated with risk of CHD, with ’always angry’ people having a greater Framingham risk score at follow-up compared to those who were ’never angry’. This result corresponded to a four-fold increase in a ten-year risk of incident CHD (4% versus 1%, respectively). Pollack et al.’s analysis showed that the relationship between anger and CHD risk may be detectable in young adulthood.
Hostility is another significant predictor of mortality and cardiovascular events in patients with CHD, as indicated by many studies, but the exact mechanisms are uncertain. Wong et al. (2013) evaluated potential mechanisms of association between hostility and adverse cardiovascular outcomes. They prospectively examined the association between self-reported hostility and secondary events (myocardial infarction, heart failure, stroke, transient ischemic attack and death) in 1,022 outpatients with stable CHD. Baseline hostility was assessed using the eight-item Cynical Distrust scale. During a follow-up time of 7.4 ± 2.7 years, the age-adjusted annual rate of secondary events was 9.5% among people in the highest quartile of hostility and 5.7% among people in the lowest quartile. After adjustment for cardiovascular risk factors, participants with hostility scores in the highest quartile had a 58% greater risk of secondary events than those in the lowest quartile. Wong et al. found that the association was mainly moderated by poor health behaviours, specifically physical inactivity and smoking.
Living with CHD is often associated with fear, anxiety, depression and stress. The sufferer may worry about heart problems or making lifestyle changes that are necessary for his/her health. Social support from family and friends can be a great help in relieving stress and anxiety. Talking and sharing are both excellent ways of reducing the burden of an illness such as CHD.
Social support is of key importance in moderating the influence of negative affect on the person’s well-being. Mookadam and Arthur (2004) systematically reviewed social support and its relationship to morbidity and mortality after acute myocardial infarction. Having low social support networks was a predictor of one-year mortality following acute myocardial infarction. Low social support is equivalent to many ’classic’ risk factors, such as elevated cholesterol level, tobacco use and hypertension. Another review found that low functional social support is associated with prevalence of CHD and all-cause mortality, but concluded that it remained uncertain whether low structural social support causally increases mortality in patients with CHD (Barth et al., 2010).
Hemingway and Marmot (1999) reviewed prospective cohort studies with healthy samples which showed a possible aetiological role for Type A/hostility (6/14 studies), depression and anxiety (11/11 studies), psychosocial work characteristics (6/10 studies) and social support (5/8 studies). In populations of patients with CHD, prospective studies showed a prognostic role for depression and anxiety (6/6 studies), psychosocial work characteristics (1/2 studies) and social support (9/10 studies). None of five studies showed a prognostic role for Type A/hostility. Although this review publication bias is always a possibility (the tendency for publications to report only positive findings), prospective cohort studies provide strong evidence that psychosocial factors, particularly depression and social support, are independent aetiological and prognostic factors for CHD.
Lack of social support predicts mortality in population studies. Orth-Gomér et al. (1993) measured emotional support from very close persons (’attachment’) and the support provided by the extended network (’social integration’). They studied a random sample of 50-year-old men born in Gothenburg, Sweden, in 1933. All men (n = 736) were followed for six years and the incidence of myocardial infarction and death from CHD was determined. Men who contracted CHD had both lower ’attachment’ and ’social integration’ scores. When controlling for other risk factors, both factors remained significant predictors of new CHD events. Smoking and lack of social support were the two leading risk factors for CHD in these middle-aged men.
Patients can find benefits of their illness in spite of pain, negative affect, many difficulties and much inconvenience to their routines of daily living. Petrie et al. (1999) investigated positive effects or changes that patients identified following a myocardial infarction (MI) or breast cancer. A total of 143 patients were assessed in hospital following a first-time MI and 52 breast cancer patients were assessed on referral for radiotherapy. Approximately three months later both groups were asked whether any positive changes had taken place in their lives following their illness. Patients were presented with a single open-ended question and their answers were read independently by three judges. Approximately 60% of each patient group reported positive changes and this was unrelated to illness severity. The most commonly reported theme by MI patients was healthy lifestyle change (68%), while many breast cancer patients reported improved close relationships (33%).
Smith et al. (2014) explored patients’ perceptions of the effect of CHD in order to identify predictors of adaptation in a cross-sectional study. In total, 548 patients were recruited from CHD registers in South London general practices. They were asked ’Has having heart disease changed your life? If so, was that change for the better, worse, both or neither?’. Participants were asked to explain their response; the explanations were subjected to content analysis. The explanations of those who said ’better’ were categorized into ’Healthier Living’, ’Recognized Mortality’ and ’Stress Reduction’ categories. For those saying ’worse’, the categories were ’Restricted Lifestyle’, ’Recognized Mortality’ and ’Loss and Burden’. More anxiety, lower functional status and self-reported chest pain were associated with saying ’worse’ rather than ’better’.
Procedurally, one might wonder about the demand characteristics of these benefit-finding study protocols. If a person is asked a question that invites the possibility of a positive answer, and he/she is implicitly led to believe that a positive answer is seen as desirable, then they are likely to give it. For example, ’It’s been raining for weeks, but have you noticed any changes for the better, worse, both or neither?’. Even though they have been miserable, confined to the house and unable to go anywhere until the rainy season was over, a person might think of the benefit that, because of the rain, they had not needed to wash their car parked outside in the drive. Notice that the option ’better’ is mentioned first in the question and the effect of this primacy is uncontrolled. Other procedures would likely yield different results.
Fear of Dying
Experiencing an acute coronary syndrome (ACS) can provoke a range of negative emotional responses, including acute distress and fear of dying. The heart is accurately viewed as the organ most essential for the preservation of life. Any perceived disturbances to the heart, especially pain, can easily trigger a fear of dying. Whitehead et al. (2005) examined the presence and severity of the fear of dying and acute distress in 184 patients with ACS. Intense distress and fear of dying was reported by 40 patients (21.7%) and moderate fear and distress by 95 patients (51.6%). Intense distress and fear were associated with female gender, lower levels of education, greater chest pain and emotional upset in the two hours before onset of ACS. Having no acute distress or fear was more common in patients who exercised regularly and who did not initially attribute the chest pain to cardiac causes. Acute distress and fear of dying predicted greater depression and anxiety one week after ACS and elevated levels of depression at three months, after adjustment for age, gender and negative affect. The authors concluded that distress and fear during the initial stages of an ACS may trigger subsequent depression and anxiety, promoting poorer prognosis and greater morbidity with time.
Malinauskaite et al. (2017) investigated whether the fear of dying after ACS can be used to predict later post-traumatic stress symptoms. They enrolled 90 patients hospitalized with a main diagnosis of ACS and assessed baseline characteristics. One month after discharge, they collected data using the Posttraumatic Stress Scale. A total of 24 patients (26.7%) were found to have developed post-traumatic stress symptoms one month after the ACS event. These patients reported significantly greater fear of dying, helplessness, avoidance-focused coping and severe anxiety.
Type D Personality
Personality test scores correlate with the mental and physical health of coronary patients. Interest has been focused on ’Type D’ (distressed) personality, a joint tendency towards negative affectivity and social inhibition. The DS14 scale is used to measure Type D personality. The scales for Negative Affectivity include items 2, 4, 5, 7, 9, 12 and 13. The content of some of these overlaps with the symptoms of depression, i.e., ’I often feel unhappy’ (4), ’I take a gloomy view of things’ (7), ’I am often in a bad mood’ (9), ’I am often down in the dumps’ (13). The fact that Type D and depression scores are positively associated is not very surprising. However, Type D personality scores can ’predict’ illness responses independently of depression scores. That said, lest there be any doubt, we do not interpret these correlations as anything other than associations, and certainly not as causes.
Personality and depression have been empirically associated in patients treated with PCI. AL-Qezweny et al. (2016) investigated the association between Type D personality at six months post-PCI (baseline) and depression at ten-year follow-up. A secondary aim tested the association between Type D personality at baseline and anxiety at ten-year follow-up. The study was done with a cohort of surviving consecutive patients (N = 534) who had undergone PCI between October 2001 and October 2002. Patients completed the Type D personality scale (DS14), measuring Type D personality at baseline, and the Hospital Anxiety and Depression Scale (HADS; Zigmond and Snaith, 1983), measuring anxiety and depression at baseline and at ten years post-PCI. At baseline, the prevalence of Type D was 25%. Type D patients were more often depressed (42%) than non-Type D patients (9%). Response rate of anxiety and depression questionnaires at ten years was 75%. At ten-year follow-up, 31% of Type D personality patients were depressed versus 13% of non-Type D personality patients. After adjustments, baseline Type D personality remained independently associated with depression at ten years. Type D showed a similar association with anxiety at ten years, albeit somewhat lower. The authors concluded that PCI patients with Type D personality had a 3.69-fold increased risk for depression and a 2.72-fold increased risk for anxiety at ten-year follow-up. There are several possible reasons for these associations other than causation, one being that Type D and depression scores are both related to a third, backgound variable yet to be determined.
Caring for Someone with CHD
Caring for a person with CHD at home can often be a stressful and distressing experience. Caregivers of CHD and stroke patients report a high level of emotional stress. And they have many unmet needs.
Anderson et al. (1995) studied factors associated with emotional distress in caregivers one year after stroke in patients with residual handicap. Their main caregivers were interviewed as part of the follow-up activities for patients (n = 492). They assessed emotional distress in caregivers using the HADS and the 28-item General Health Questionnaire. Of 241 patients who survived one year after stroke and were living outside an institution, 103 patients (43%) were handicapped, of whom 84 patient/caregiver units were assessed. Anderson et al. reported that almost all caregivers reported adverse effects on their emotional health, social activities and leisure time, and more than half reported adverse effects on family relationships. Altogether, 46 caregivers (55%) showed evidence of emotional distress, particularly if they were caregiving for patients with dementia and/or abnormal behaviour.
Moser and Dracup (2004) compared the emotional responses and perception of control of MI and revascularization patients and their spouses, and examined the relationship between spouses’ emotional distress and patients’ emotional distress and psychosocial adjustment to their cardiac event. They found that spouses had higher levels of anxiety and depression than the patients. There were no differences in level of hostility. The patients also had a higher level of perceived control than did the spouses. Spouse anxiety, depression and perceived control were correlated with patient psychosocial adjustment to illness even when patient anxiety and depression were kept constant. The patients’ psychosocial adjustment to illness was worse when spouses were more anxious or depressed than patients. Attention should be given to the psychological needs of spouses of patients who have suffered a cardiac event. Moser and Dracup also found that patients’ psychosocial adjustment was best when patients were more anxious or depressed than spouses. This finding suggests that interventions that address the psychological distress of spouses may well improve patient outcomes.
Johnston et al. (1999) evaluated the effectiveness of a cardiac counselling rehabilitation programme for MI patients and their partners. They found that the programme resulted in more knowledge, less anxiety, less depression and greater satisfaction with care for both patients and their partners, and less disability in patients. This study was published five years earlier than the Moser and Dracup (2004) study in the same journal, thus highlighting that it can take a long time for research findings to be disseminated, synthesized and put into practice. Conducting research to influence practice is very time consuming and there are usually many barriers to overcome. In order for research to have an impact, health psychologists must have an awareness of promotional techniques, the politics of the context in which they practise and the power of economical factors.
One problem for evaluation of cardiac patients’ experience of QoL is identifying an instrument that is not only reliable and valid, but also responsive to change. Instruments that are not very responsive will tend to under-represent the benefits of programme attendance. Research indicates that the most responsive instruments are the Beck Depression Inventory, Global Mood Scale, Health Complaints Checklist, Heart Patients’ Psychological Questionnaire and Speilberger State—Trait Anxiety Inventory.
Rees et al. (2004) reviewed psychological interventions for CHD, typically stress management interventions. They included randomized controlled trials, either single modality interventions or a part of cardiac rehabilitation with a minimum follow-up of six months. Stress management (SM) trials were identified and reported both in combination with other psychological interventions and separately. The quality of many trials was poor, making the findings unreliable. The authors concluded that psychological interventions showed no evidence of effect on total or cardiac mortality, but small reductions in anxiety and depression in patients with CHD. Similar results were seen for SM interventions when considered separately.
Interventions for CHD
People with suspected CHD usually undergo several different tests for absolute diagnosis and to determine the best treatment to relieve symptoms. These include stress exercise tolerance test (ETT), electrocardiogram (ECG) and coronary angiogram. Seeking a diagnosis can be a stressful time for people with suspected CHD and their family and friends. Patients commonly feel apprehension about the procedure and find some parts of the procedure are unexpected, with doctors’ technical language being an obstacle to understanding.
Many people with CHD are recommended to make lifestyle changes and take a regime of medication such as ACE inhibitors, statins, anticoagulant drugs and beta-blockers. Clinical guidelines are not always implemented because of a lack of time for physicians, who only have a few minutes to discuss risk factors, lifestyle changes or treatment. This may not be an appropriate time to discuss such issues with a patient, who may well feel shocked by the diagnosis of being at risk of CHD and they may also show low levels of compliance with physician advice.
Riesen et al. (2004) acknowledged that, although high rates of compliance with lifestyle changes and lipid-lowering agents are reported in clinical trials, rarely are the findings reproduced in regular practice. They recommended the use of educational materials as well as regular telephone contact to improve compliance. However, further research is needed into the causes of poor compliance and methods of improving adherence with lipid-lowering agents. We now turn to discuss interventions for the two main categories of CHD patients, those with MI and those with angina.
Guidelines for the management of CHD recommend cardiac rehabilitation, or ’cardiac rehab’ (CR). This is a structured programme of rehabilitation for people who have had a heart attack, heart failure, heart valve surgery, coronary artery bypass grafting or PCI. It involves making changes towards a more ’heart-healthy’ lifestyle to reduce established risk factors for cardiovascular disease. CR will typically include exercise training, education on heart-healthy living and counselling to reduce stress. CR aims to improve the participants’ health and quality of life, reduce the need for medication, decrease heart or chest pain and the chance of recurrence. CR is usually provided in an outpatient clinic or hospital rehab centre. The CR team includes doctors, nurses, exercise specialists, physical and occupational therapists, dietitians or nutritionists, and mental health specialists. A standard CR programme includes 36 supervised sessions over 12 weeks.
In 2007, the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation reported on the core components of CR/secondary prevention programmes (Balady et al., 2007). The associations recommended that all CR/secondary prevention programmes should contain baseline patient assessment, nutritional counselling, risk factor management (lipids, blood pressure, weight, diabetes mellitus and smoking), psychosocial interventions, and physical activity counselling and exercise training. CR services are now routinely offered to patients, but many invited patients fail to attend the sessions. Cooper et al. (2002) reviewed the literature. The results showed that non-attenders are more likely to be older, to have lower income/greater deprivation and to deny the severity of their illness, and are less likely to believe they can influence its outcome.
A large number of MI patients do not return to work or regain normal functioning despite being physically well. There is evidence that CR programmes can reduce distress and disability, increase confidence and improve modifiable risk factors. However, many patients do not attend rehab programmes after their MI. Patients’ beliefs about their illness are alleged to be determinants of recovery after an MI. Petrie et al. (2002) evaluated a brief hospital intervention designed to alter patients’ perceptions of their MI. The content of the intervention was individualized according to the patients’ responses on the Illness Perception Questionnaire (Weinman et al., 1996). The intervention caused significant positive changes in patients’ views of their MI. The intervention group reported being better prepared for leaving hospital and subsequently returned to work at a significantly faster rate than the control group. At the three-month follow-up, the intervention group reported a significantly lower rate of angina symptoms.
Cooper et al. (1999) investigated whether the illness beliefs held during their hospital stay by patients who had an MI or who had undergone CABG could predict CR attendance. As well as being older, less aware of their cholesterol values and less likely to be employed, non-attenders were less likely to believe their condition was controllable and that their lifestyle may have contributed to their illness. Stewart et al. (2004) found a difference in the health information needs between men and women recovering from an acute coronary event. Men who had received significantly more information reported a greater satisfaction with health care professionals meeting their information needs. Women reported wanting more information than men concerning angina and hypertension. Men wanted more information about sexual function. Patients who reported receiving more information reported less depressive symptomatology. Most patients of both sexes preferred a shared decision-making role with their doctor. The majority felt their doctor had made the main decisions. CR that is individualized to patients’ needs may be more attractive and effective than thinking of CR as a place to do exercise and be informed about lifestyle changes. However, individually tailored CR is costly and demand far outstrips supply.
Evaluations of CR have used a variety of methods, including RCTs, observational studies and qualitative studies. RCTs of cardiac rehabilitation following MI typically demonstrate a lower mortality in treated patients, but a statistically significant reduction is generally lacking. In an early review, Oldridge et al. (1988) carried out a meta-analysis on the results of ten RCTs that included 4,347 patients (control: 2,145 patients; CR: 2,202 patients). The pooled odds ratios of 0.76 for all-cause death and of 0.75 for cardiovascular death were significantly lower in the rehab group than in the control group, with no significant difference for non-fatal recurrent MI. The results suggested that comprehensive CR has a beneficial effect on mortality but not on non-fatal recurrent MI.
However, findings concerning CR have been modest and not always consistent, and doubts about the applicability of evidence from existing meta-analyses of exercise-based CR have been raised. In addition, the current model of CR delivery (e.g., 36 exercise and educational sessions delivered three weekly for 12 weeks) no longer appears to be financially viable or sustainable due to multiple factors, as recently reviewed in detail (Arena, 2015; Sandesara et al., 2015). Also, only a fraction of eligible patients are able to participate in and complete CR.
One of the primary sources for state-of-the-art reviews of therapies is Cochrane, previously known as the Cochrane Collaboration. Cochrane is an independent, non-profit, non-governmental organization consisting of a group of around 40,000 volunteers in more than 130 countries. Cochrane was founded in 1993 and conducts systematic reviews of RCTs of health care interventions and diagnostic tests.
Anderson et al. (2016) updated the Cochrane systematic review and meta-analysis of exercise-based CR for CHD. They included RCTs with at least six months of follow-up, comparing CR to no-exercise controls following myocardial infarction or revascularization, or with a diagnosis of angina pectoris or CHD defined by angiography. A total of 63 studies with 14,486 participants with median follow-up of 12 months were included. CR was associated with a reduction in cardiovascular mortality (relative risk: 0.74) and the risk of hospital admissions (relative risk: 0.82). However, no significant effect occurred on total mortality, myocardial infarction or revascularization. The majority of studies (14 of 20) also showed higher levels of health-related QoL following exercise-based CR compared with control conditions. This study confirmed in a fairly conclusive manner that exercise-based CR reduces cardiovascular mortality, hospital admissions and improvements in quality of life. According to the reviewers, these benefits were consistent across patients and intervention types and were independent of study quality, setting and publication date.
The Cochrane review by Anderson et al. led to a call in the Journal of the American College of Cardiology to ’rebrand and reinvigorate’ CR. Lavie et al. (2016: 14) have suggested that:
Alternative secondary prevention models do not need to replace conventional CR, but they should be used to reach a much larger patient population over an extended duration, that is, well beyond the traditional 12-week window. With such efforts, not only will CR be increasingly employed, but also an enhanced and invigorated CR brand may transform its effect from the individual to the population level and re-establish, or even improve upon, the previously reported overall mortality benefits of this intervention.
Angina affects more than 50 million people worldwide. Some of the major concerns for people living with angina are the regular occurrence of chest pain, anxiety, fear of dying and depression. Providers of interventions have needed to consider efficient ways of reaching the maximum audience in the most cost-effective manner.
One intervention in the UK has combined professional and lay practitioners. Lewin et al. (2002) evaluated the efficacy of a cognitive behavioural therapy (CBT) disease management programme, the Angina Plan (AP; Box 22.1), to aid the psychological adjustment of patients with newly diagnosed angina. At six-month follow-up, AP patients showed a significantly greater reduction in anxiety, depression, frequency of angina, use of glyceryl trinitrate and physical limitations. They were also more likely to report a change in diet and they increased their daily walking.
Box 22.1 The Angina Plan: A Psychological Disease Management Programme for People with Angina
The Angina Plan (AP) consists of a patient-held booklet and audio-taped relaxation programme. Before commencing the 30—40-minute AP session, the patient is sent a questionnaire designed to establish whether she/he holds any of the common misconceptions about angina (e.g., each episode is a mini-heart attack or angina is caused because the heart is worn out). The patient’s partner or a friend is invited to the session.
After blood pressure has been taken and body mass index has been recorded, the AP facilitator discusses any misconceptions that were revealed in the questionnaire with the patient and, if possible, his or her partner in an effort to correct their understanding. Personal risk factors are identified and personal goals to reduce the risk factors are then set. They are provided with a relaxation tape and encouraged to use it. The Plan also contains written information, such as the role of frightening thoughts and misconceptions in triggering adrenaline (epinephrine) release and anxiety, and how this can result in poor coping strategies.
The patient is contacted by the facilitator at the end of weeks 1, 4, 8 and 12. During these phone calls, the patient is praised for any success. They are also asked whether they want to extend successful goals. Unsuccessful goals can be revisited. Adding procedures that encourage specific implementation intentions to this programme could well improve the success of the AP.
Zetta et al. (2011) carried out a trial to evaluate the AP against standard care (SC) with 218 hospitalized angina patients assessed pre-discharge and six months later. A structured interview, self-report and physiological measurement were used to assess between-group changes in mood, knowledge and misconceptions, cardiovascular risk, symptoms, QoL and health service utilization. The intention-to-treat analysis found no reliable effects on anxiety and depression at six months. However, Zetta et al. found that AP participants reported increased knowledge, less misconceptions, reduced body mass index, increased self-reported exercise, less functional limitation, as well as improvements in general health perceptions and social and leisure activities compared to those receiving SC.
Source: Lewin et al. (2002)
Nelson et al. (2013) conducted a qualitative study as part of an RCT comparing a lay-facilitated Angina Plan with usual care. The aim was to explore participants’ beliefs, experiences and attitudes to the care they had received during the trial, particularly those who had received the angina management intervention. They ran four participant focus groups during 2008; three were with people randomized to the intervention (n = 10) and one with those randomized to control (n = 4). The authors state that both similarities and differences were observed between control and intervention groups. Similarities included low levels of prior knowledge about angina, whereas differences included a perception among intervention participants that lifestyle changes were more easily facilitated with the help and support of a lay worker. Nelson et al. concluded that lay facilitation with the Angina Plan is perceived by the participants to be beneficial in supporting self-management. However, clinical expertise is required to meet the more complex information and care needs of people with stable angina.
Another method has been to provide an internet-based intervention. Devi et al. (2014) evaluated the effectiveness of a web-based CR programme for people with angina. They conducted an RCT recruiting angina patients from GPs in primary care to an intervention or control group. The intervention group were offered a six-week web-based rehabilitation programme (’ActivateYourHeart’). The programme was introduced face-to-face and then delivered via the internet without further face-to-face contact. The programme contained information about CHD and set goals around physical activity, diet, managing emotions and smoking. Performance against goals was reviewed during the programme and goals were reset as they went along. Participants completed an exercise diary and communicated with rehab specialists through an email link/chat room. The control group continued with GP treatment as usual, which consisted of an annual review. Outcomes were measured at six-week and six-month follow-ups during face-to-face assessments. A total of 94 participants were recruited and randomized to the intervention (n = 48) or the usual care (n = 46) group; 84 and 73 participants completed the six-week and six-month follow-ups, respectively.
The average number of log-ins to the programme was 18.68, an average of three per week per participant. Change in daily steps walked at the six-week follow-up was +497 in the intervention group and —861 in the control group. Significant effects were observed at the six-week follow-up in energy expenditure, duration of sedentary activity, duration of moderate activity, weight, self-efficacy, emotional QoL score and angina frequency. Significant benefits in angina frequency and social QoL scores were also observed at the six-month follow-up. The results of this trial suggest that an internet-based secondary prevention intervention is both feasible and acceptable to people with angina, although it is necessary to run a trial with a larger sample. The use of the internet for CHD interventions has good potential.
Hostility and chronic stress are known risk factors for heart disease. Eichstaedt et al. (2015) used language on Twitter to characterize community-level psychological correlates of age-adjusted mortality from atherosclerotic heart disease (AHD). They used data from 1,347 US counties for which the following were accessible: AHD mortality rates; county-level socio-economic, demographic and health variables; and at least 50,000 tweeted words. More than 88% of the US population lives in the included counties. Eichstaedt et al. (2015: 159) stated their findings as follows (see Figure 22.3):
Language patterns reflecting negative social relationships, disengagement, and negative emotions—especially anger—emerged as risk factors; positive emotions and psychological engagement emerged as protective factors. Most correlations remained significant after controlling for income and education. A cross-sectional regression model based only on Twitter language predicted AHD mortality significantly better than did a model that combined 10 common demographic, socioeconomic, and health risk factors, including smoking, diabetes, hypertension, and obesity. Capturing community psychological characteristics through social media is feasible, and these characteristics are strong markers of cardiovascular mortality at the community level.
Figure 22.3 Community-level psychological correlates of age-adjusted mortality from atherosclerotic heart disease (AHD)
Map of counties in the northeastern United States showing age-adjusted mortality from atherosclerotic heart disease (AHD) as reported by the Centers for Disease Control and Prevention (CDC; left) and as estimated through the Twitter-language-only prediction model (right). The out-of-sample predictions shown were obtained from the cross-validation process described in the text. Counties for which reliable CDC or Twitter language data were unavailable are shown in white
Source: Eichstaedt et al. (2015). Public domain
Eichstaedt et al. (2015: 164) obtained three findings:
First, language expressed on Twitter revealed several community-level psychological characteristics that were significantly associated with heart-disease mortality risk. Second, use of negative-emotion (especially anger), disengagement, and negative-relationship language was associated with increased risk, whereas positive-emotion and engagement language was protective. Third, our predictive results suggest that the information contained in Twitter language fully accounts for — and adds to — the AHD-relevant information in 10 representatively assessed demographic, socioeconomic, and health variables. Taken together, our results suggest that language on Twitter can provide plausible indicators of community-level psychosocial health that may complement other methods of studying the impact of place on health used in epidemiology … and that these indicators are associated with risk for cardiovascular mortality. Our findings point to a community-level psychological risk profile similar to risk profiles that have been observed at the individual level.
1. We need to know more about the potential role of lay practitioners in the delivery of angina and MI interventions on a wider scale than is possible at present.
2. The association and role of depression in recurrence of CHD episodes needs further study in large-scale trials with robust designs.
3. The delivery of web-based systems of intervention and support using social media and apps warrants in-depth examination.
4. More qualitative research is necessary to enable interventions to be fine-tuned to meet the unmet needs of patients.
1. CHD is a leading cause of death which can bring many medical and psychosocial issues into the lives of patients and their caregivers.
2. The two main forms of CHD are myocardial infarction and angina, which are both related to a narrowing of coronary arteries caused by plaque.
3. Decreases in the CHD death rates are mainly due to reduction of a few major risk factors, principally smoking.
4. Seeking treatment for CHD can be stressful for both people with CHD and their family members.
5. Psychological disease management can help angina patients to adjust, but psychological services are currently patchy and inadequate.
6. The positive role of social and emotional support from family and friends has been repeatedly demonstrated in relief of stress and anxiety.
7. Cardiac rehabilitation has been shown to be effective in reducing cardiovascular mortality, hospital admissions and improvements in quality of life, but it is accessible to only a minority of cardiac patients.
8. An angina self-management plan has been shown to enable significant gains, including increased knowledge, reduced body mass index, less functional limitation and improvements in general health perceptions.
9. The challenge of delivering interventions that are effective and cost-efficient can be met using a combination of professional, lay and web-based provision.
10. Language used on Twitter has been statistically analysed to characterize community-level psychological correlates of age-adjusted mortality from atherosclerotic heart disease (AHD).